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Inflammatory Bowel Disease Flashcards

(46 cards)

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1
Q

Which two conditions form IBD?

A

Crohn’s Disease

Ulcerative Colitis

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2
Q

What do Crohn’s and UC have in common?

A

Idiopathic
Chronic
Inflammatory

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3
Q

Where is the incidence of Crohn’s most common?

A

Western countries

North of Scotland

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4
Q

Factors Contributing to the Pathogenesis of IBD

A

Genetic predisposition
Mucosal immune system
Environmental triggers

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5
Q

Genetics in IBD

A

Positive family history is best established risk factor
Early onset may have stronger links
Specifically, NOD2 gene on IBD-1 of chromosome 16

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6
Q

Theories of IBD Pathogenesis

A

Pathogenic bacteria
Abnormal microbial composition
Defective host containment of commensal bacteria
Defective host immunoregulation

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7
Q

Environmental Factors in IBD

A

NSAIDs risk for IBD
Smoking =
Aggravates Crohn’s
Protective in UC

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8
Q

UC - Clinical Features

A

Peak in 20-30s
Relapsing course
Affects rectum, proximally and continuously

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9
Q

UC - Disease Extent

A

Proctitis
Left-sided colitis
Pancolitis

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10
Q

UC - Natural History

A

Variable
15% develop sever attack
of these, 30-40% will fail to respond and require surgery

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11
Q

UC - Symptoms

A 
Diarrhoea + bleeding
Night rising 
Increased bowel frequency 
Urgency 
Tenesmus
Incontinence 
Lower ado pain (LIF)
Constipation with proctitis
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12
Q

IBD - Important Features of History

A 
Recent travel 
Antibiotics
NSAIDs 
Family history 
Smoking 
Skin, eyes, joints
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13
Q

UC - Determining Severity

A 
>6 bloody stools/24 hrs
\+ 1 or more of:
Fever 
Tachycardia 
Anaemia
Elevated ESR/CRP
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14
Q

UC - Further Assessment

A

Albumin (inflammation detection)
Plain AXR
Endoscopy
Histology

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15
Q

UC - Plain AXR

A

Stool absent in inflamed colon
Thumb printing = mucosal oedema
Toxic megacolon = Transverse >5.5cm, caecum >9cm

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16
Q

UC - Endoscopy

A 
Loss of vessel pattern
Granular muscosa
Contact bleeding
Ulcers
Poss pseudopods (mostly benign)
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17
Q

UC - Histology

A

Inflammation to mucosal layer ONLY

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18
Q

UC - Long Term Complication

A

Increased risk of colorectal cancer:
Severity
Duration
Extent

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19
Q

UC - Extra Intestinal Manifestations

Study These Flashcards
A 
Skin - erythema nodosum
Joints - axial and peripheral pain
Eyes - pain, redness
Deranged LFTs 
Oxalate renal stones
20
Q

UC - Primary Sclerosing Colangitis

Study These Flashcards
A

Inflammatory condition affecting biliary tree
Fibrotic strictures
Histology with onion skin appearance
Mostly asymptomatic, or itch and rigors
HIGHLY increased risk of cholangiocarcinoma/colorectal cancer

21
Q

Crohn’s - Onset

Study These Flashcards
A

Earlier onset than UC

Mean age 27, but 15% before 15

22
Q

Crohn’s - Distribution

Study These Flashcards
A

Any region of GI tract
Skip lesions
Transmural inflammation

23
Q

Crohn’s - Peri Anal Disease

Study These Flashcards
A 
Recurrent abscess formation 
Pain 
Can lead to fistula with persistent leakage 
Damaged sphincters
Incontinence
24
Q

Crohn’s - Natural History

Study These Flashcards
A

25% continuous disease
50% intermittent flares
75% need surgery within 8-10 years

25
Crohn's - Symptoms (Determined by Site)
Small Intestine = peri-umbilical abdo cramps, diarrhoea, weight loss Colon = lower abdo cramps, bloody diarrhoea, weight loss Mouth = painful ulcers, swollen lips, angular chielitis Anus = peri anal pain, abscess
26
Crohn's - Assessment
Clinical Exam = weight loss, RIF mass, peri anal signs Bloods = CRP, albumin, platelets, B12, ferritin Colonoscopy Histology
27
Crohn's - Histology
``` Cobble-staining Thickened wall Fissures Transmural Patchy GRANULOMAS ```
28
Crohn's - Small Bowel Assessment
Barium follow through Small bowel MRI Technetium labelled white cell scan
29
Therapy - Lifestyle Advice
``` Stop smoking (aggravates Crohn's) Dietary factors - may influence symptoms ```
30
UC - Drug Therapy Options
5ASA (mesalazine) Steroids Immunosuppressants Anti-TNF therapy
31
Crohn's - Drug Therapy Options
Steroids Immunosuppressants Anti-TNF therapy
32
5ASA - Mechanism of Action
Topical effect (lessens systemic effects) Anti-inflammatory properties Reduces risk of colon cancer
33
5ASA - Side Effects
Diarrhoea | Idiosyncratic nephritis
34
5ASA - Routes of Administration
Oral = Prodrugs pH dependent release Delayed release Topical = Suppositories Enemas
35
5ASA - Suppositories vs Enemas
Suppositories - Generally sufficient for proctitis Coat lees than 20cm, but better mucosal adherence Enemas - Foam or liquid (patients generally prefer foam) Less than 10% remain in rectum
36
Corticosteroids - Mechanism of Action
Systemic inflammatory properties E.g. prednisolone, budesonide Aim to reduce remission Given as a short course with high initial dose, reducing over 6-8 weeks
37
Corticosteroids - Side Effects
``` High dependency MSK = osteoporosis, avascular necrosis GI = nausea, vomiting, bleeding Cutaneous = Acne, skin thinning Metabolic = Weight gain, diabetes, hypertension Neuropsychiatric = manic, depression, disturbed sleep pattern Cataracts Stunted growth (esp. when given to younger patients) ```
38
Immunosuppression - Use
When most potent suppression of inflammation is needed UC = steroid sparing agents Crohn's = maintenance therapy E.g. azathioprine/mercaptopurine
39
Immunosuppression - Mechanism of Action
Purine analogue which interferes with DNA synthesis | Can be given as a prodrug
40
Immunosuppression - Azathioprine
``` Slow onset of action (16 weeks) TPMT activity contributes to toxicity Avoid with XO inhibitors Regular blood monitoring needed Side Effects = pancreatitis, leucopaenia, hepatitis, small risk of lymphoma and skin cancer ```
41
Anti-TNFa Therapy - Mechanism of Action
TNFa = pro-inflammatory cytokine Antibodies = infliximab, adalimumab Promote apoptosis of activated T lymphocytes Rapid onset of action
42
Anti-TNFa Therapy - Safety Issues
Infusion reactions Infection Cancer (lymphoma, solid tumours)
43
Anti-TNFa Therapy - Use
Part of long term strategy, including immune suppression, surgery, supportive therapy Refractory/fistulising disease
44
Crohn's - Surgery
Minimise amount of bowel resected NOT CURATIVE Repeated resection may lead to short gut syndrome and need for parenteral nutrition
45
UC - Surgery
CURATIVE | Permanent ileostomy or restorative proctocoloectomy and pouch
46
Therapy Pyramid
``` Smoking cessation 5ASA (UC only) Steroids if needed Immunosuppression Anti-TNFa therapy Surgery - may be best treatment in some ```

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